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CDA Example Task Force
SDWG formed the CDA template example task force to collect and share member submitted samples. The committee is currently hosting bi-weekly meetings on Thursdays from 12-1 PM Eastern. Subscribe to the SDWG listserv for more information.
Contents
Formatting of CDA Template Samples
PROTOTYPIC TEMPLATE
- Meaningful template example name (hyperlinked)
- Approved by: (list all approving bodies, including approval date)
- TemplateId(s) illustrated: (include hyperlinks where possible)
- CDA Implementation Guide where template(s) is(are) defined: (include hyperlinks where possible)
- Reference to full CDA sample: Full example in validated document (hyperlinked)
- Custodian: (who is the steward of the referenced sample? include email address)
- Validation location: (list of all validators tested against)
- Comments: (free text comments about the example)
Examples - Organized by Section
ALLERGIES AND ADVERSE REACTIONS
- No Known Allergies with Author Timestamp (GitHub)
- Approved by: Task force on 1/9/2014. Approved by SDWG 1/16/2014.
- TemplateId(s) illustrated: Allergy Concern Act (2.16.840.1.113883.10.20.22.4.30) and Allergy Intolerance Observation (2.16.840.1.113883.10.20.22.4.7)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: No Known Allergies in compliant MU2 Sample (via GitHub)
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a patient has no known allergies.
GENERAL PATTERN - NO INFORMATION
- No Information Problems Section (via GitHub)
- Status: Approved on task force 1/30/2014; Approved by SDWG on 2/6/2014.
- TemplateId(s) illustrated: Problem Section with Coded Entries(2.16.840.1.113883.10.20.22.2.5.1)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example (although not by MU2 validator today)
- Reference to full CDA sample: No Information Problem section
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record a section contains No Information. This is an exceptional case and does not cover 'No Known' scenarios. See No Known Allergies with Author Timestamp (GitHub) for an example of 'No Known'.
IMMUNIZATIONS
- Unknown Patient Immunization Status (via GitHub)
- Approved by: Task force on 11/21/2013. Approved by SDWG 12/5/2013.
- TemplateId(s) illustrated: Immunization Activity (2.16.840.1.113883.10.20.22.4.52)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Immunization section in compliant MU2 C-CDA sample
- Custodian: Brett Marquard, brett@riverrockassociates.com (GitHub: brettmarquard)
- Validation location: SITE Validator TOC Ambulatory
- Comments: This is an example of how an author can record they do now know whether the patient has received any vaccinations.
MEDICATIONS
- Patient prescribed oral medication QID PRN without precondition specified
- Approved by: Task force on 1/9/2014.
- TemplateId(s) illustrated: Medication Activity Medication Information Precondition for Substance Administration (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example when PRN but no precondition specified
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Keywords: Precondition, Pre-coordinated medication code, dose frequency
- Comments: This is an example of a medication which is QID and PRN (as needed) but with no precondition specified. It was generated based on SDWG list-serv discussion in December 2013. It also demonstrated a pre-coordinated generic medication coded at the SDC level (generic 600mg Oral Tablet) in RxNorm hierarchy.
- Patient prescribed medication every 4 to 6 hours
- Approved by: Task force 1/30/2014. Approved by SDWG on 2/6/2014.
- TemplateId(s) illustrated: Medication Activity Medication Information (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Keywords: Dose frequency, pre-coordinated medication
- Comments: This is an example of a medication (Sudafed) which to be administered every 4-6 hours, a common dosing pattern. Representing the range of potential of hours is done through a low and high child element of the period within effectiveTime of PIVL_TS.
- Patient prescribed oral antibiotic with a dosing regimen that varies over course of prescription
- Approved by: Not yet approved
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Keywords: Pre-coordinated medication code, dose frequency
- Comments: This is an example of a common pattern for antibiotic administration which is complex (double dose on day 1, commonly known as Z-PAK). There was SDWG discussion of an appropriate means to structure this information in February 2014.
- Patient prescribed basal insulin administered at bedtime
- Approved by: Not yet approved
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 27, 2014
- Keywords: Pre-coordinated medication code, dose frequency
- Comments: This is an example of a subcutaneous dose of a common basal insulin. Please note that this insulin dosage does not vary. This dose is administered at bedtime so the dosing frequency utilizes EIVL_TS type to denote this.
- Patient administered two baby aspirin at single point in time
- Approved by: Not yet approved
- TemplateId(s) illustrated: Medication Activity Medication Information
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference in full CDA Sample: Results Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 27, 2014
- Keywords: Pre-coordinated medication code, dose frequency
- Comments: This is an example of a medication administered at a single point in time. It includes supply information since it was administered in the past.
- Patient with no medications intended to be taken - current medication list has no medications.
- Full alternative no known medications which validates
- Not Yet Approved
- TemplateId(s) illustrated: Medication Activity where moodCode="INT" 2.16.840.1.113883.10.20.22.4.16
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: not yet validated in document shell; [
- Custodian: Lisa R. Nelson LisaRNelson@cox.net
- Validation location: TTT
- Comments: Need to add section narrative text and then validate the sample. Key thing to review at this point is the need to populate the substanceAdministration/code element so that negationInd can work.
PROBLEMS
- Patient with No Known Problems - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
- Not Yet Approved
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: Full Sample No Known Problems
- Custodian: Brett Marquard
- Validation location: TTT VDT Ambulatory
- Comments:
- Patient with No Known Problems, No finding of back pain - Problem Section 2.16.840.1.113883.10.20.22.2.5.1 (via GitHub)
- Not Yet Approved
- TemplateId(s) illustrated: Problem Section, Problem Concern Act, Problem Observation
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R1.1
- Reference to full CDA sample: https://github.com/LisaRNelson/LRN_HL7_CDA_Examples/blob/master/Doc-No%20Known%20Problems%2020140203.xml
- Custodian: Lisa R. Nelson LisaRNelson@cox.net
- Validation location: TTT
- Comments: Update the statusCode of the "concern tracker" to be active; Fixed effectiveTime of "concern tracker" to have more precision - to suggest it is a time stamp assigned by a computer; Added more authors to inspire discussion about what "persistent authorship" means and how it works; Added a second entry to see test if the usage of observation.valueNegationInd could remain our single pattern
RESULTS
- Result with less than a specified value (via GitHub)
- Approved by: Reviewed with SDWG on 12/5/2013. Patrick will review with OO and report back.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of how to encode "less than" a specific range when returned from lab equipment. The example is for BNP, an immunoassay where the lower threshold for detection is often 5 pg/mL. The lower bound of the interval is zero in this example, even though this is none may be specified, since zero is the lower bound for measures of physical quantity. This example also includes a structured reference range.
- Result panel with the display of two ordinal values of negative/positive
- Approved by: Task force on 11/21/2013. Ready for SDWG review.
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of how to encode positive and negative, which are common data types returned form lab equipment. While some technologies may represent this as a type of ST (string), it is logical and easily possible to encode this information using SNOMED-CT. This would allow structured examination of this information downstream as well as comparison to a structured reference range, as shown in the example.
- Result with an unstructured string as the value (e.g. urine color)
- Approved by: Not yet approved
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated December 18, 2013
- Comments: This is an example of a value from a lab result that may not be structured.
- Result which requires translation for its unit represented in UCUM
- Approved by: Not yet approved
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.1 (Trifolia Log-in Required) 2.16.840.1.113883.10.20.22.4.2 (Trifolia Log-in Required)
- CDA Implementation Guide where template(s) is(are) defined: C-CDA 1.1
- Known bad example?: Valid example
- Reference to full CDA sample: Result Packaged in C-CDA Skeleton
- Custodian: John D'Amore, jdamore@diameterhealth.com (GitHub: jddamore)
- Validation location: NIST TTT Message Validator for VDT Ambulatory validated February 12, 2014
- Comments: This is an example of a value from a lab which requires a translation for its unit. All units for physical quantities should be represent in UCUM.
KNOWN BAD EXAMPLES
- Future bad examples will go here.
FEEDBACK AND AWAITING RESPONSE
- Result with less than a specified value (via GitHub)- Awaiting review from Patrick Lloyd with OO
COMMUNITY REQUESTS FOR EXAMPLES (include name, email)
- I would like an example of a preliminary lab result (John Doe, JohnDoe@email.com)
- The SMART C-CDA Collaborative generated a list of approximately 50 requested samples here. See the section noted as "Annotated Examples." For more information on the SMART C-CDA Collaborative please visit here. (Ashley Swain, ashley.swain@lantanagroup.com, John D'Amore, jdamore@diameterhealth.com, Josh Mandel, jmandel@gmail.com)
DRAFT MATERIAL - PLEASE DON'T DELETE
How to Setup an XML example from GitHub
- Sign up for GitHub account. It's free and quick
- Once you've got an account, you will be able to fork repositories and comment on examples through the website
- To post and manage examples, you will likely want to install a graphical user interface for GitHub. Here's where you can download: For Windows or For Mac
- Once you've got the application installed, there are a few steps:
- Click the "create" button to make a repository where you would like to upload/update to GitHub
- Once you've created, the repository will exist online and on your local machine
- On your local machine, place in new or revised files in the local folder (this will generally be under Documents/GitHub). It's good practice to include a text file named README.md, which appears online when people browse your repository. This is a good place to explain what you're working on.
- Once you've made the edits (or new files) you want to post to GitHub, "commit" the sample entering a description and then hit the "sync" button to upload
- At this point the changes and new files are posted online publicly
- For an example GitHub repository with C-CDA samples, check out this one from Children's Hospital Boston
- Add instructions for how to upload examples (to github, to other sites)
- Add examples (to site of your choosing)
- Add link and metadata too
- enumerated lists
- validators
- approving bodies
- SDWG
- Infoway
- NHS
- validators
HOW TO PREPARE A SAMPLE FOR APPROVAL BY SDWG
Observing these guidelines will streamline the process for all involved.
- Include XML comments that will:
- Make assumptions explicit
- Annotate each lines
- Highlight choices and key decisions that were made
- Confirm statusCode/moodCode/effectiveTime are in agreement
- Snippet should be in the context of a section
- Confirm narrative to match entries - and content is linked
- Does final sample name accurately reflect the final sample
- Add disclaimer at the top of every sample: SAMPLE DEVELOPED BY HL7 SDWG SAMPLES TASK FORCE - PLEASE SEE http://wiki.hl7.org/index.php?title=CDA_Example_Task_Force FOR ADDITIONAL DETAILS
- Patient with allergies to different substances (via GitHub)
- Approved by: Not yet approved
- Patient taking pre-coordinated medication (via GitHub)
- Approved by: Not yet approved
- Copy and paste the template below, and complete for your sample
- Allergy to Substance X
- Approved by: SDWG (Oct 31, 2013); NHS (Oct 31, 2013)
- TemplateId(s) illustrated: 2.16.840.1.113883.10.20.22.4.30; 2.16.840.1.113883.10.20.22.4.7
- CDA Implementation Guide where template(s) is(are) defined: C-CDA R2
- Reference to full CDA sample: N/A
- Custodian: John Doe (John.Doe@email.com)
- Validation location: validator.com
- Comments: This is the best example EVER!
